In response to a growing
chorus of complaints from pain patients and the doctors who treat them,
who say that heavy-handed drug law enforcement is leaving patients in pain
and innocent doctors behind bars, the Drug Enforcement Administration (DEA)
and leading pain specialists have coauthored a new set of guidelines spelling
out how to prescribe opioid pain relievers such as morphine or Oxycontin
without running afoul of the law. But while the guidelines are a
consensus effort between drug enforcers and academics, they are not winning
universal approval among pain relief advocates.

In recent years, hundreds
of doctors have been prosecuted or sanctioned by state medical control
boards as "Dr. Feelgoods" or drug traffickers by state or federal officials
who view their prescribing practices as excessive. Those cases have
become harder to prosecute as doctors have begun fighting back, and pain
patient advocates have joined the fray, charging that the DEA crackdown
on prescribing is leaving millions of Americans suffering needless pain.
But they still have a devastating impact on physicians' willingness to
prescribe pain medications.

The consensus statement was
produced by experts from the DEA, the University of Wisconsin Pain and
Policy Studies Group, and Last Acts (http://www.lastacts.org),
a national coalition of consumer and professional organizations working
to improve end-of-life care through the use of palliative medicine and
pain management techniques. Last Acts and the DEA signed an earlier
consensus statement stressing the need for "balance" between law enforcement's
demand to prevent drug abuse and diversion and the medical imperative to
treat the sick in 2001.

But with the White House
Office of Drug Control Policy having declared war on prescription drug
abuse this year and the prosecution of physicians for alleged over-prescribing
continuing apace, doctors are reluctant to prescribe medically acceptable
quantities of opioid pain relievers for fear of being stripped of their
practices, subjected to criminal prosecutions, and possibly sentenced to
decades in prison, pain relief advocates say. Thus the publication
of "Prescription Pain Medications: Frequently Asked Questions and Answers
for Health Care Professionals and Law Enforcement Personnel."

The document is intended
to clarify matters for physicians and law enforcement alike. And
it does make clear that opioids such as Oxycontin are legitimate pain medications,
that they are sometimes subscribed in large quantities, that they are sometimes
prescribed to large numbers of patients by one doctor or clinic, and that
none of these things necessarily imply shady doctoring.

That is a critical message,
study coauthor David Joranson, pain policy director at the University of
Wisconsin-Madison Medical School, told the Associated Press. Fewer
doctors are willing to prescribe opioid pain relievers because of fear
of prosecution, he said. "In some ways, pain management and the use
of pain medications has become a crime story when it really should be a
healthcare story," Joranson said.

The key message for law enforcement
is that opioid pain relievers, even in large quantities, are good medicine,
said Dr. Russell Portenoy, head of New York's Beth Israel Medical Center
pain center. "These are legitimate treatments. They're essential
for good medical care," he told AP.

The DEA will distribute the
document to agents and prosecutors, said Patricia Good, the agency's drug
diversion head. Helping law enforcement distinguish aggressive pain
management from criminal over-prescribing would help remove the "unwarranted
fear that doctors who treat pain aggressively are singled out," she said
in a notice announcing the document. The information should help
eliminate that "aura of fear," she said.

But parts of the guidelines
have pain relief advocates and doctors concerned. Some activists
said medicine is being perverted by the war on drugs with recommendations
such as the following, which are designed to help doctors weed out "drug
abusers" and protect themselves from arrest:

"Records should show evidence
that the doctor evaluated the nature and impact of the pain, earlier treatments,
and alcohol and drug history. Measuring pain intensity and extent
of relief over time 'is important evidence of the appropriateness of therapy.'

"More worrisome signs include
deterioration in functioning at home or work, illegal activities such as
stealing or forging prescriptions, and repeatedly 'losing' prescriptions."

Frank Fisher

"Look, let me say there are
some good features in this, but it's fundamentally misguided," said Dr.
Frank Fisher, a California physician who underwent a five-year legal ordeal
before being exonerated of all charges -- including spurious murder charges
-- after being raided by state officials over his opioid prescribing practices
(http://www.drfisher.org).
"For the last 15 years, we've been doing this sort of thing -- intractable
pain acts, patients' bills of rights, medical board guidelines, consensus
statements like this one -- in recognition of the terrible public health
problem with chronic pain. None of that has worked," he told DRCNet,
"and this is more of the same."

Guidelines seeking "balance"
between law enforcement and medicine fail to get to the root of the problem,
Fisher said. "This doesn't address the underlying flaw in our social
policy and legal approaches to the regulation of these medicines and how
that affects the treatment of pain," he argued, calling the involvement
of the criminal justice system in medicine a "fundamental structural problem
in the law."

And that is prohibition.
"By making opioids illegal," said Fisher, "prosecutors will have to decide
who to prosecute, and to do that, they will have to apply some sort of
standards to medical practices, which effectively has them regulating the
medical system. This document is nothing more than a reiteration
of the status quo that says let's keep doing all these things, the
DEA is going to play nice, and you physicians shouldn't be so scared, but
I find it terrifying," he said.

There was progress in some
small sense, said Siobhan Reynolds, executive director of the Pain Relief
Network (http://www.painreliefnetwork.org),
a pain patients' advocacy group. "Well, it's the first time the DEA
even admitted they had created an aura of fear," she told DRCNet.
"But this will not remove the aura; it will only make things worse," she
said. "What this does is criminalize in writing the application of
the principles of pain management in their pure form. The doctors
are supposed to practice with an eye to law enforcement concerns."

"Basically, addiction medicine
doctors have adopted the dual concept of being a doctor and a cop, and
this document is an astonishing display of paternalism," said Reynolds.
"Academic pain medicine has been co-opted. What we are really talking
about here with these 'drug abuser' profiles is the denial of the autonomy
and dignity of patients and their civil rights when it comes to the practice
of medicine," she argued. "These doctors think they're doing the
right thing," said Reynolds, "but there is such a gap between what these
academics see and what is actually happening to patients. There are
50 million people in chronic pain and maybe 7-9 million in out-of-control
pain, and they're worried about a handful of 'drug abusers'?"

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